jamescalumcampbell

In the review of the Sunday papers on yesterday’s Andrew Marr Show, Sarah Baxter, deputy editor of the Sunday Times, picked out of the Sunday Telegraph a story about The Beatles.  Apparently it still irks Sir Paul McCartney that John Lennon’s assassination elevated him to “James Dean” status and made him, as it were, Head Beatle. As if these terrible events outside the Dakota in New York had been some kind of career move.  I was – still am – a huge Beatle fan and, like any other aficionado, can remember what I was doing when I heard of Lennon’s murder.  For the record, I was a medical student, travelling between Edinburgh Royal Infirmary and Monkland’s Hospital in Airdrie.  It came on the car radio.  I wasn’t entirely surprised.  It seemed to me that Lennon had assumed – unwittingly for all I know – a kind of Messianic status that made him peculiarly vulnerable to attack.

Do you know that experience in which something that happens to be on your mind turns up in the Sunday papers?  The Beatles had been on my mind, for a rather odd, and tenuous, reason.  I’ve spent the last few days on the Moray Firth, in glorious summer weather.  I took a walk from Nairn, on a path by the Nairn River, to Cawdor.  I said to the hotel receptionist, “I’m just going over to pay my respects to the Thane.”  She looked blank.  And as I took that beautiful woodland walk I found myself whistling a wistful tune that hasn’t crossed my mind for years.  Lennon’s threnody to his mother, Julia.

The Thane of Cawdor was, of course, king hereafter.  I don’t care to revisit The Scottish Play but I’ve just reread J Wilson Knight’s essay on Macbeth in The Wheel of Fire – Macbeth and the Metaphysic of Evil.  Wilson Knight understood Macbeth as Roman Polanski understood it.  I went to see the Roman Polanski film of Macbeth in 1971, and within a minute of its start I knew I was going to be confronted with a terrible vision of absolute evil.  By the end of the film I had an inkling of the meaning of the word “catharsis”.  The purgation of pity and terror.

Roman Polanski was married to Sharon Tate.  She was brutally murdered in 1969.  The murderer is reputed to have scrawled on the wall, in blood, at the murder scene, the words “Helter Skelter”.  Helter Skelter is a track on the twin LP compilation officially entitled The Beatles, but commonly known as the Double White Album.

The Beatles were an extraordinary phenomenon.  Their time in the sun was brief.  Beatlemania erupted in 1963, and by 1966 they had left the stage at Candlestick Park, entered the recording studio, and turned recluse.   Their explosion on to the scene was inexplicable.  The demo tapes they sent to Decca aren’t that impressive.  If I’d auditioned them then I doubt if I would have taken them on.   They did covers of ancient songs like Besame Mucho and The Sheik of Araby.  There’s a basic competence no doubt achieved through the endless Hamburg gigs.  But nothing terribly original.  There’s something in their early rendition of Money – a kind of upbeat, nervy intensity.

Then something happens.  Aspects of it can be described, but it cannot really be explained.  The tempo slows down, and the incessant beat is accentuated.  And there is the unique and unreproducible mix of McCartney’s lyric tenor voice, and Lennon’s, a voice of harsh, desperate passion.  And, most crucial of all, they started to sing their own music.   George Martin their inspired producer at Parlophone got them into a studio where they pretty much produced an album in a day, full of simple and ingenuous songs like Ask Me Why and P.S. I Love You.

With the Beatles came out on November 22^nd 1963 – not exactly a slow news day.  (Aldous Huxley died, et al.)  Its opening track, It Won’t be Long is utterly extraordinary.  It closes with another rendition of Money and a chance for Lennon to lacerate his voice as he did with Twist and Shout.

Then comes A Hard Day’s Night and I remember being completely beguiled by its final track, I’ll be Back, which was a deliberate contrast to the rabble-rousing finales of the previous two LPs.

I think probably the first side of A Hard Day’s Night shows The Beatles at the height of their powers.  There’s a popular notion abroad that the Beatles’ late work is the greatest.  The idea is that Sergeant Pepper was ground breaking, revolutionised popular music, set the bar, and took it to new heights.  I see it as quite the opposite – the commencement of a descent into an abyss that is as inevitable and unstoppable as the group’s extraordinary rise.   There’s already a hint of it in the last track of Revolver.  Lennon called it his “Tibetan book of the dead” phase.  Things are beginning to go a bit psychedelic.  This reaches an apotheosis at the end of Pepper in A Day in The Life, which culminates in a huge improvised orchestral cacophony.  Where will they go from here?

Answer:  The Double White Album.

I haven’t listened to The Double White Album for years.  I thought to revisit it for purposes of this blog, but, to be honest, I can’t face its unremitting bleakness.  From Back in the USSR to Good Night – “nothing is but what it is not”.  Everything is sarcastic.  This is music of absolute despair.  It can only head in one direction.  In the penultimate track, Revolution 9, we descend into a heavily drugged world of fleeting impression and psychedelic madness.  The final track is a kitsch version of how a TV transmission service might close down.  Its cynicism is complete.

The early stuff is the best.  It is encapsulated in its own time and in the world of vinyl.  And nobody other than The Beatles seem able to perform it.  All these covers of Yesterday by lush string orchestras – they don’t really work.

It seems to me that The Beatles were as surprised as anybody else by the extraordinary roller coaster ride of their brief career.  Like the characters in Macbeth, they seemed to have no control over events.  Yet it is to their credit that they somehow got together to get back to their roots in Let it Be, and express some kind of farewell in Abbey Road.  In You Never Give me Your Money, and Golden Slumbers, there’s a kind of fin de siècle frailty, the poignancy of damaged people remembering the past.

Did Helter Skelter cause a murder?  Of course not.  You might As well say Gotterdammerung caused The Third Reich.  Of course that’s rubbish.  As Mark Twain said, Wagner’s music is much better than it sounds.

In the film Dead Poets Society, John Keating, a charismatic and inspirational English teacher, returns to the school where he was a pupil, a US boys’ academy hothousing the future doctors, lawyers, bankers, and captains of industry bound for the Ivy League.  Here he offers his students an alternative and perhaps subversive educational experience.  He invites one of them to read to the class the introduction to a poetry anthology, Understanding Poetry by one J. Evans Pritchard.  This expounds a literary theory which evaluates a poem according to two criteria, perfection and importance.  These can be graphed on an x and y axis such that the overall worth of a poem is represented by an area on the graph.  Mr Keating draws the graph on the board and the class dutifully copy it down.  But they are brought to a sudden halt by his comment.

“Excrement.”

In Waterstone’s the other day I paused to look at the medical section.  I like to keep my finger on the pulse.  I noticed there was an entire shelf given over to a variety of textbooks more or less bearing the same title, “How to get into Medical School”.  I thumbed through a few of them, with a sickly fascination.  They mostly followed the same format and dealt with the same issues, in largely the same way.  Getting good grades at school is de rigueur.  In addition, you need to do well at one of the Clinical Aptitude Tests now required by most universities – UKCAT or BMAT or GAMSAT.  This needs rehearsal.  Then you would be wise to accrue some work experience relevant to the health sector, perhaps a holiday job in a care home, a hospice, or hospital.  Try to shadow a general practitioner and spend some time observing at outpatient clinics.  If you are taking a gap year, it would be good to spend time in a developing country, doing voluntary work.

With respect to your application, visit the med schools that attract you and find out what they have to offer.   Take the greatest care to hone a beautifully crafted Personal Statement, and rehearse endlessly for the interview, fielding all the standard questions as well as a few unpredictable googlies.  You get the picture.

If I were mentoring a prospective medical student, I would certainly encourage all of the above.  I would even suggest they read some of the “How to get into Med School” books.  I’ve just finished reading “Get into UK Medical School for Dummies” (Wiley, 2013) – rather an oxymoronic title considering how difficult it is to get in.  Maybe it refers to a specific institution – “I won a place at UKMSD.”  Anyway it contains lots of sound advice and I would happily recommend it.

What I would hesitate to do is tell that prospective medical student what I really think, namely, that  the whole of that particular bookshelf, the whole project, is a steaming pile of… well, what was that word Mr Keating used?

There’s a piece of medical propaganda that it suits the universities, and the profession, to peddle.  It is that, in order to study medicine, you need to be a cross between Albert Einstein and Mother Theresa.  And it would be helpful if you spent your summer holidays solving the Ebola crisis.  It’s a myth.  If you have enough native wit to gain a sound knowledge of pathophysiology, and if you are kindly, caring, and conscientious, then you can be a good doctor, perhaps even a great one.  There are plenty of young people out there with solid, if not exceptional, exam grades, who would love to study medicine, but who never get the chance.

I found myself wondering whether, if I were applying for medical school now, I would have any chance of getting in.  I was a graduate student, and I gather some of the med schools attach more weight to graduates’ UKCAT performance.  So out of curiosity I got some practice questions and had a go.  UKCAT is a psychometric test, measuring your thought processes.  It’s in five parts: verbal, quantitative, and abstract reasoning, decision analysis, and situational judgment.  No special knowledge is required to sit the test, and indeed any person who had done reasonably well academically at school could, given plenty of time, walk in off the street and make a pretty good fist of it.  What makes the test difficult is the time constraint.  To complete the test, you need to answer 231 questions in two hours.  That averages just over half a minute per question, and most of the questions are quite lengthy.

With my confidence lately boosted by imminent publication of my novel, I thought I might try the verbal reasoning subset.  You read 11 passages of prose and mark 4 statements on each passage as being “true”, “false” or, on the information given, “can’t tell”.  You have 22 minutes to complete the subtest.

The first piece of prose was 250 words long, and contained a lot of detailed information.  I read it in a minute.  That left me a minute to answer the questions, but it took me two minutes, and then I got one wrong.  Then I started to pick a fight with the examiners.  “No no no.  That’s not right!”

The quantitative reasoning subset was worse.

With abstract reasoning and decision analysis, UKCAT becomes surreal.  You enter the realm of Bletchley Park and decipher hieroglyphics.  Oddly enough I did quite well at that, and that puzzled me.  Then it twigged.  I’m a crossword addict.  It’s really all about practice.

I was amused to find myself looking, as a prospective medical student would, for the tricks of the trade that would allow me to perform better in the tests.  Clearly, you can’t sit down with a cup of coffee and read these 11 segments of prose in a “normal” way.  Probably best to skim read them, then read the questions and cherry-pick the answers.  If in doubt, write “can’t tell”.  There’s no negative marking so you have nothing to lose.

Ridiculously, I found myself considering practising a bit to improve my performance.  It’s my own personal Myth of Sisyphus.  Having completed a career in medicine, I’m obliged to go back to med school and start rolling that boulder up the hill again.

But really, who makes this stuff up?  And why?  All prospective medical students have already been educated, excruciatingly, to breaking point.  Why subject them to this?  It’s a form of abuse really.  Prospective medical students are talented people.  Put a hurdle in front of them and they will probably surmount it.  It doesn’t really matter how ridiculous the hurdle is, it will be hurdled.  It’s like a concert pianist playing The Minute Waltz in 31 seconds.  You marvel at it.  Yet something is missing.  Like… Chopin.

The real irony is, while our universities are going to immense trouble to select and train these pedigree racehorses, you can’t find a doctor when you need one for love nor money.  (Well, maybe for money.)  Two weeks to see a GP, six months to see a neurologist…  All the doctors in their 20s are leaving for Australia, and all the doctors in their 50s are just leaving.  It’s enough to make you roll up to the med school interview in jeans and T-shirt and without a care in the world.

“Mr Campbell, why should we offer you a place ahead of the other interviewees?”

“Well, I don’t know any of them.  You decide!”

“You tell us about your strengths in your Personal Statement.  What would you say is your weakness?”

“I’ve got a bit of a drink problem.”

Of course it’s just a fantasy.  Like everybody else, I would present a strength disguised as a weakness.  “I’m terribly impatient.”  This can be translated as, “I’m clear headed, decisive, and dynamic.”  Sounds a bit arrogant, so needs to be tempered.  “I need to take time to listen, and to understand an opposing point of view.  I’ve been working at this, and have found the satisfaction of learning to be a team player immensely rewarding.”

Makes you want to throw up.

But if there’s one thing you learn in medicine, it’s to play the game.  So you turn up in your charcoal suit, exchange some charcoal blandishments, and recycle some charcoal ideas.  But make sure you throw in something a bit different that will make them remember you.   Like your burgundy tie, nothing off the planet.

I once went for an interview and didn’t give a damn.  I sat the Civil Service graduates’ entrance exam (in a freezing building on St Vincent St Glasgow during a power cut) and passed it, and got invited down to Whitehall for one of these intense two day goldfish bowl experiences where psychologists watch you chair board meetings.  My fellow candidates all seemed to have gone to Haberdashers and Eton.  I must have looked, and sounded, like a Martian.  And at the interview:

“What is it that attracts you to the Civil Service?”

“Nothing much.  I’m thinking of applying to med school.”

Oddly enough, they didn’t throw me out on my ear.  Well, not right away.

If you stay in medicine for long enough, eventually you cease to be an interviewee and become an interviewer, when remarkably talented people say to you, “I’ll give the job 110%.”

“Oh don’t do that.  You’ll be burned out in 2 years.”

“I’m not afraid of hard work.”

“Oh yeah?  Well I am.  I’m absolutely terrified of it!”

I thought these thoughts, but I never actually voiced them.  The fact is that, as a teacher and mentor, you have to be very careful about introducing your students to the attractions of being maverick.  There’s a subtle, barely articulated implication in Dead Poets Society, that Mr Keating, for all his remarkable inspirational gifts, was a bit naïve.  Of course it is quite right to say that when a tragedy occurs in the school, he is scapegoated and hung out to dry.  A colleague of Keating, Mr McAllister, very nice, empathetic, old-fashioned Scottish dominie tries, in the gentlest fashion, to warn him.  And just before the school lets Keating go, he and the Scotsman catch sight of one another, through a window and across a quad, and exchange a friendly wave.

Neil Perry is the boy who plays Puck in A Midsummer’s Night Dream, who wants to act, but whose overbearing father is forcing him to be, of all things, a medical student.  Neil says to Mr Keating, “I’m trapped.”  And Mr Keating says, “No you’re not.”  Within that simple exchange lies the whole beauty of the medical consultation.  UKCAT doesn’t know anything about that.

Mr Keating’s students find a copy of their teacher’s year book.  “John Keating.  Keats.  Man most likely to do anything.”  I co-edited our medical class final year book.  No, that will never do.  Far too uppity.  Rework it for the Personal Statement.  “I was lucky to have the chance to contribute to the editing of our final year book.  I was terribly impressed, and rather humbled, by the range and depth of my colleagues’ extracurricular activities…”  Well, that’s true.  One woman boosted the finances by driving a heavy goods artic down the M1, and another by shouting the odds at the dogs at Powderhall in Edinburgh.  But they didn’t do it to enhance the CV; they just had an instinctive notion of how to get a life.  Maybe Wiley and Sons could commission them to write, “How to get a life for dummies.”  It would be the absolute antithesis of “How to get into Med School”.  I think it would resemble a letter of advice I feel inclined to write to my young pre-med self:

“Relax; calm down; chill.”

I’m thinking of consulting a clinical psychologist with regard to my OCD.  I’m having the greatest difficulty getting out of the house in the morning.  Have I switched off the kettle and the toaster?  Is the hot water immersion heater on?  What about the radio, the telly, the computer, and is the back door open?  Then, getting into the car, did I lock the front door?  Did I switch the lights off?  Better go back and check. And then of course, if you get interrupted during the checks, you can’t just resume where you left off; you need to start again.  You stand staring at the cooker master switch and intone, “Off off off off off!”  But somehow, you just can’t “learn” its offness. The fridge is OK.  (As Michael McIntyre has said, why do we trust the fridge?) Then, more bizarrely, have I left the glass paperweight too near the window and is it going to deflect magnified sunlight on to my draft novel and ignite it?  In Scotland?  I ask you. But I’m going back to check.  The neighbours are beginning to suspect.  “He’s just left the house.  Watch this.  In a moment he’ll turn around and go back.  There he goes!”

I’m thinking of writing out a checklist that I could use to facilitate my morning egress, ticking off each item as I go.  Checklists have a noble provenance and a fine track record for safety.  Think of aviation.  I have a PPL and, oddly enough, I can sit at the holding point and carry out the “vital actions” (they really are vital) once, and then forget about it.  People have tried to export checklists out of aviation and into medicine.  The surgeon Atul Gawande is a fan.  See his book “The Checklist Manifesto: How to Get Things Right” (Metropolitan Books, 2009).  In theatre, I always found the ritual of two nurses counting the swabs out loud, in unison, deeply comforting.  Then, as the surgeon is closing up, they repeat the mantra.  “I counted them all out, and I counted them all back.”  Yet many surgeons grumble about checklists.  They say they get in the way.  Actually I think they have a point.  People can get obsessed with process.  GPs now complain that their consultations are constantly being disrupted by a welter of checklists appearing on the computer screen.  Have you checked smoking status, cholesterol, weekly alcohol units, weight…  when all the time the patient wants to talk about something completely different.  Even aviation recognises that checklists are subsidiary to the art of flying.  When your engine fails, the first thing to do is not reach for the checklist, but fly the plane.

Yet some checking procedures are so vital that they are best learned by rote and committed to memory for ever.  I remember when I did a twin engine type-rating in New Zealand (the aircraft was a Beechcraft B76 Duchess with the beguilingly affirmative call sign Yankee Echo Sierra), I had difficulty mastering the procedures, and enacting them, following the failure of one engine after take-off.  From time to time you hear on the news of such an event, the pilots being unable to avert a tragedy, and indeed precipitating it, by shutting down the wrong engine.  You can see how such a thing would happen; two hundred feet off the ground there is a catastrophic loss of power, and the aircraft is yawing all over the sky.  This is when you need to enact a response so hard-wired as to be unconscious and automatic.  So there is a mantra you learn.  I remember – it was 1997 – I was on the phone to my father in Scotland describing all this.  He had been a pilot in RAF Coastal Command.  The last time he had flown a plane in earnest was on September 9^th 1945 when he flew from Ikeja to Accra.  (I have his log books in front of me now.)  He said to me, immediately and without hesitation, “Mixture, props and throttles forward, gear up, flaps up, identify, verify, feather!”

This business of rehearsing for an emergency is very important.  One of the most enlightening presentations in medicine I ever went to was one which in my ignorance I tried to avoid.  But it turned out to be compulsory – part of some damned bureaucrat’s checklist.  It was given not by a health professional but by a Fire Prevention Officer with a laconic US drawl and a dry sense of humour.  He was a terrific communicator.  For the first time, I understood fire risk.  He showed a brief – how brief – video of the inside of a department store filmed from a CCTV security camera.  Some draperies caught fire and within the course of two minutes the entire store was a raging inferno.  Then we all went outside and practised extinguishing fires.  Fire extinguishers are designed to be simple but you still need to know which extinguisher to apply to which fire, and how to turn it on, point it, and, as it were, fire it up.  It’s exactly like so many instruments in medicine.  The first time you use a cricothyroidotomy set, you don’t want to be in earnest.

So nowadays I take fire seriously.  If I’m staying in a hotel I actually read that notice about fire exits on the inside of the door, then I rehearse the route, and imagine finding it in the dark, or in thick smoke.

And that’s the trouble with my OCD.  It has a perfectly rational basis.  The laconic US Fire Prevention Officer told me never to leave the house empty with an appliance running.  So I shut my computer down and it says, “Checking for updates.  Do not switch off your computer.  It will turn off automatically.”  Aye right.

Clearly then, it’s all a question of balance.  Maybe if I can whittle the list down to three, at most four vital actions.  And do them once and once only.  Pretend you’re in the cockpit.  The Cherokee Warrior 2 has an avionics master switch.  One switch shuts everything down.  That’s what I need.  To hell with it.  I’d rather the place went up in a puff of smoke than that I continue to live in fear and trembling.  It’s a form of timidity really.

At last!  I’m out, into the car, and away!  No regrets.  Make the journey, park the car.  Brake on, into first gear, steering column locked, lights off, windows closed, valuables out of sight.  Off we go.

Did I lock the car?

Did you watch Napoleon last Wednesday (9.30, BBC2)?  Since he was 10 years old, historian Andrew Roberts has held Bonaparte in high regard.  Bony has had rather a bad press for two centuries now, but according to Professor Roberts, he was a splendid chap.  Hell of a fellow, actually.  Well, it’s a timely revision; next Thursday is the two hundredth anniversary of the Battle of Waterloo at which it is estimated 47,000 soldiers were killed or wounded.

I slept on it.  Have you noticed the way a TV programme or a film stays with you, and resonates throughout the following day, the themes, the dramatis personae, the script, the music.  Yet, unaccountably and apparently irrelevantly, I woke up thinking about Beethoven, and about two contrasting chords – E minor, and E flat major.

At the start of his novel The Unbearable Lightness of Being, Milan Kundera remarks on the way that History is expunged of the agony of the present precisely because it has been consigned to the past.  He found himself looking at pictures of Hitler and recalling memories of his childhood with nostalgia.  Could we bear to examine the French Revolution if its existence were ongoing?  An eternity of heads being chopped off.   He muses throughout the book about the contrast between the importance western culture places on gravitas, and the gossamer transience of a life lived solely in the present.  And, towards the end of the novel, he recalls the rather portentous quotation Beethoven places above the last movement of his last work, the string quartet Opus 135 – weightily, and in F minor, Muss es sein? – and then lightly, and in F major, Es muss sein!  It sounds like something from the Heiligenstadt Testimony – I will seize fate by the throat!  But it turns out to be a joke about Beethoven’s laundry bill.  It seems extraordinary that even Beethoven is capable of self-parody in the style of Presley in sequins, doing Elvis impersonations at Vegas.

Is there some way of recapturing the agony of the past?  Yes.  Visit a place that is locked into the past and incapable of breaking free.  Gibraltar.  Strange place.  Reminiscent of Belfast, full of union flags and ancient parapets scrawled with graffiti – No surrender!  In Gibraltar, we are still fighting the Peninsular Wars.  Young men cruise the streets in open top sports cars with the sound system blaring, a remnant of imperialist tub-thumping.  If you come down off the rock, past the Rock Hotel and the Botanic Gardens towards the ancient naval battlements, you come upon a cemetery full of sailors from Trafalgar.  The names on the headstones bring the past into the present; two hundred and ten years is but the blink of an eye.

Another way of visiting the past is to read the words of contemporaries.  Beethoven again.  Napoleon was born in 1769, and Beethoven in 1770.  Beethoven had dedicated his Eroica Symphony to Bonaparte, but when he learned that France’s First Consul had crowned himself Emperor on May 20^th, 1804, he famously flew into a rage, and said, “Now he, too, will trample on all the rights of man!”  He tore the symphony’s title page in two, and scratched out the name “Buonaparte” with such ferocity as to dig a hole in the paper.

Lord Byron also had a change of heart about Napoleon.  He was born in 1788.  His Ode to Napoleon Buonaparte is caustic in the extreme.

Thine only gift hath been the grave / To those that worshipped thee; / Nor till thy fall could mortals guess / Ambition’s less than littleness!

When Arnold Schoenberg set Lord Byron’s Ode to music in 1942, he was doubtless thinking of another “little corporal”.  It is a serial work based on a tone row – E – F – D flat – C – G sharp – A – B – B flat – D – E flat – G – F sharp, but it is surely no coincidence that its final chord is E flat major, the home key of the Eroica.

Sir Walter Scott’s one essay into biography was The Life of Napoleon Buonaparte.  Scott was born in 1771.  The first edition of The Life, published simultaneously in French, German, Italian, and Spanish, was a spectacular commercial success.   Of particular interest with regard to Andrew Roberts’ programme is Scott’s treatment of the taking of Jaffa by the French in 1799:

The place was carried by storm – 3000 Turks were put to the sword, and the town was abandoned to the license of the soldiery, which, by Buonaparte’s own admission never assumed a shape more frightful.

And of the Egyptian prisoners taken –

This body of prisoners was marched out of Jaffa, in the centre of a large square battalion… They were escorted to the sand-hills to the south-east of Jaffa, divided into small bodies, and put to death by musketry.  The execution lasted a considerable time, and the wounded were despatched with the bayonet. 

And one final near contemporary – Thackeray, born 1811.  Musing on the night of June 18^th, 1815:

There is no end to the so-called glory and shame, and to the alternations of successful and unsuccessful murder, in which two high-spirited nations might engage.  Centuries hence, we Frenchmen and Englishmen might be boasting and killing each other still, carrying out bravely the Devil’s code of honour.

So we return to the present, and to Prof Roberts’ ongoing assessment of his childhood hero.  Part of the young Napoleon’s spectacularly successful Italian campaign was the pillage of Milan and Padua, the systematic looting of Michelangelos, Raphaels, and Caravaggios, and their transport in carriages to the Louvre.  Some people have been critical of that.  Mr Roberts’ comment – “They need to get over themselves.”  Then we come to that segment which, I confess, really got up my nose and made me write this blog, the treatment of the Jaffa atrocity of March 9^th 1799 when Napoleon exacted reprisals on up to 4000 prisoners by systematically bayoneting them to death on the beach.  Prof Roberts admitted that such an event would now be regarded as a war crime.  But not then.  The most Prof Roberts could bring himself to say of his great hero was that this was “not his finest hour”.

It’s a common enough argument, the idea that in assessing the actions of the past, we must have due regard for the mores of the time, and not apply the standards of our own morality retrospectively.

I don’t believe in this argument; I don’t buy it.  For as long as Homo sapiens has walked the planet, and perhaps for even longer, any of our ancestors being marched down to the beach to be bayoneted has felt – aside from terror – a sharp sense of disgruntlement and injustice.  Murder is as old as time itself.  Is this why we appear to be the only “sapient” species on earth, because we have killed off all the opposition?  Cain murders Abel in Genesis chapter 4.  The archetypical stories of our collective consciousness tell us we have always known that murder is the greatest wrong.  Yet in the dismal recapitulation of blood and gore through the centuries that continues to be our idea of the study of History, we continue to spew out the usual apologias – he solved the unemployment problem…  he got the trains to run in time… okay it wasn’t his finest hour…

Waterloo is a little distraction from the current, burdensome four year celebration of war we are less than a year into.  I’d like to hear a bit more Sassoon –

“He’s a cheery old card”, grunted Harry to Jack / As they slogged up to Arras with rifle and pack.

But he did for them both with his plan of attack.

I’d like to hear a bit more Owen –

My friend, you would not tell with such high zest / To children ardent for some desperate glory / The Old Lie: Dulce et decorum est / Pro patria mori. 

Now I know why I woke up thinking about Beethoven, and E flat.  But why E minor?

The answer lies in the Sixth Symphony of Ralph Vaughan Williams.  RVW quotes the Eroica in the second movement of the sixth.  He takes the repeated three note motif of the introduction of the last movement of the Eroica and transforms it into something inhuman, mechanistic, and hellish.  The last movement of the sixth, so reminiscent of Neptune, the last of The Planets by his good friend Gustav Holst, never rises above pianissimo.  Some people think of it as a depiction of a nuclear winter.  RVW, great exponent of the Anglo-Saxon litotes tradition, always abhorred the imposition upon music of a programme, but at least he admitted that that very beautiful but deserted music is “full of meaning, and tension”.  In the end, it settles on a chord of E flat, which is a chord of resolve, and of resolution.  Then it elides into a chord of E minor, which is a chord of anxiety and trepidation.  And you wonder which way it is going to go.  So finally, it settles on to a chord of E flat, and fades out towards silence, much as Holst’s Neptune fades out.

Then, almost inaudibly, it slips back into E minor.

Around the millennium I took a sabbatical from the world of medicine, buried myself away in a croft on the Isle of Skye, and wrote a book (or at least, put a series of black marks on paper).  Then my mother’s cousin broke her leg.  She was the front seat passenger in a car which suddenly decided to traverse Somerled Square and crash into the Portree Hotel.  I visited her in Broadford Hospital, where the medical director said to me, “You’re the doc who’s holed up in Camustianavaig writing a book.  Do you want a job?”  I have no idea how he knew where I was.  Anyway I did a locum.

Then the 2001 general election came along and the local MP, Charles Kennedy, dropped into the hospital with his (then) wife Sarah.  They were both very nice.  Mr Kennedy had a self-deprecatory sense of humour and was entirely lacking in pretence.  We had a very easy conversation.  I think the reason why the news of his death has caused such genuine sorrow is that he had a warm personality and an ability to connect with people.  I for one felt a sharp pang of dismay when I first heard the news last Tuesday morning.  I was reminded of the sudden death of another Scottish politician, Robin Cook, who collapsed and died in August 2005 while walking on Ben Stack, in Sutherland.  Mr Kennedy and Mr Cook both opposed the 2003 Iraq war, a stance which was, amid the prevailing attitudes of the time, courageous.  Robin Cook’s memoire of the run-up to the war, The Point of Departure, ends with his House of Commons speech of resignation from the government. It is very compelling.  This also reminds me of Mr Kennedy, when he was leader of the Liberal Democrats, arguing in the House that he was not persuaded of the justification to go to war.  A background to his speech was the inane hubbub coming from the opposite benches.

Mr Kennedy’s ability to connect also reminded me of New Zealand.  In an Auckland emergency department one night I looked after a government minister who came in with an acute medical problem.   We were so busy that at one point I had to wheel his trolley out into the corridor (sounds familiar?) to free up a resuscitation room.  I was apologetic but he just wanted to be treated like everybody else.  (Incidentally we sorted the overcrowding issue out; it took a decade, but that’s another story.)  I was reminded of this Kiwi egalitarianism when in February this year the British Government appointed a New Zealand judge, Justice Lowell Goddard, to lead the independent enquiry into child sexual abuse in England and Wales.  She was the third appointee; Baroness Butler-Sloss and then Fiona Woolf had taken on the task only to withdraw, because it was felt they were both too close to the Establishment they were being asked to investigate.  Justice Goddard, on her arrival in the UK, was asked if she might not also have links with the British Establishment.   She replied that she had had to check out what British people meant by “establishment”.  She said, “We don’t have such a thing in my country.”

I think she’s right.  That is not to say that there isn’t a degree of class consciousness in New Zealand.  Most of it comes as a legacy from Great Britain.  A posh New Zealand accent is a kind of approximation of BBC RP, although it is beginning to sound very old fashioned.  I have dined in Auckland restaurants when I’ve seen New Zealanders cringe to hear the waitress (sorry, I believe the current idiom is “wait-person”) announce, “The fush of the dee ees sneepah.”  And, later, “Would yous like to see the dessert menu?”  (The latter made me feel right at home.)

Yet I think the real reason why New Zealand doesn’t have an establishment is that it has unicameral government.  The upper chamber was abolished in 1950.  They decided they didn’t need it.

Back here, after this year’s general election there was the state opening of parliament with the arrival of the Queen in a gold horse-drawn carriage, the usual Black Rod flummery and the MPs filing in pairs through to join the ermine in the Lords, before the thrones, the page boys, the ladies in waiting.  This is the fundamental problem with the UK – the complete disconnect between the establishment and the commonweal.  I think most people living in the UK look at this spectacle and conclude that they have nothing to do with it, and it has nothing to do with them.

Of all the anecdotes I’ve heard about Charles Kennedy over the past week, the one I liked best concerned an elderly pensioner who came to see him in his constituency surgery.  She had been complaining to the council for years about a dripping tap in her kitchen, and nobody was bothering.  Mr Kennedy said, “I will fix it.”  He took along his tools and replaced a washer.

Actually I’m a bit worried about our Lords and commoners.  They don’t have enough room.  For the Queen’s speech they’re packed in like sardines.  Any time I go to a medical conference one of the first house-keeping notices in the plenary session is to go over the fire drill and indicate the location of the fire exits.  Do they ever have fire drills in the Lords?  Remember, it’s still legal to smoke in parts of the Palace of Westminster, and the glorious interiors are made of wood.  It’s a disaster waiting to happen.

We pass from last week’s dreams to, this week, The Dream, via politics.  On Wednesday May 27^th in Edinburgh the Scottish Parliament debated the Assisted Suicide (Scotland) Bill (it was knocked back by 82 votes to 36), and on Saturday May 30^th in Glasgow the Royal Scottish National Chorus and Orchestra performed Elgar’s Dream of Gerontius.

While it is not illegal to commit suicide in Scotland, it is not lawful to assist someone to do so.  This is what the Bill seeks to change.  I thought it would be worthwhile to give the Assisted Suicide (Scotland) Bill close scrutiny.  It’s not a lengthy document – 20 pages, including the 9 forms that it would be necessary to fill out if one chose to go down the assisted suicide route.  It’s worth talking through the forms, because this gives a sense of what it would mean in reality if the Bill were to become law.

You start by filling in “Preliminary declaration of willingness to consider assisted suicide”.  It’s a very simple form: name and address, date of birth, medical practice name and address.  You sign and date a declaration that you are willing to consider requesting assistance to commit suicide.  You need to be registered with a medical practice, and over 16.  You need to be making the decision voluntarily having been neither persuaded nor influenced by another person to make it.  At this stage, you can be in perfect health.

The preliminary declaration must be witnessed.  The Witness Statement is the next form.  Name and address, date of birth (over 16 again), signed, dated.  You must be acquainted with the applicant, but not a relative, spouse, in-law, civil partner, or cohabitee.  You mustn’t stand to gain financially from the proposed suicide, and you mustn’t be a doctor or nurse providing care to the person in relation to their illness or condition.  The same disqualifications apply to proxies and persons providing assistance in the act of suicide, “licensed facilitators”.

Next is a “Note by Registered Medical Practitioner” to state that the first two forms have been accurately filled in.  Name and address, signed, dated.

Now at least a week must elapse, for reflection.

Next is the “First request for assistance in committing suicide”.  Name and address, date of birth, medical practice name and address, signed, dated.  You declare that your quality of life has become unacceptable, because you have an illness that is either terminal or life-shortening, or you have a condition that is progressive and either terminal or life-shortening, and you see no prospect of any improvement in your quality of life.  The apparent distinction between an “illness” and a “condition” is not explained.

Next form is “First registered medical practitioner’s statement on first request”.  Name and address, signed, dated.   The doctor is not being asked to make any kind of value judgment as to whether or not the first request is justified, merely that the first request form has been properly filled out and that the information it contains is “not inconsistent” with the facts currently known to the doctor.

Next form is the “Second registered medical practitioner’s statement on first request”.  This is essentially the same form as the above.  The second doctor needs to interview the applicant.

At least 14 days must now elapse.

Next form is the “Second request for assistance in committing suicide”.  Name and address, date of birth, medical practice name and address, signed, dated.  This is largely a repetition of the first request with the additional declaration that you have arranged to have the services of a “licensed facilitator”.

Next form is the “First medical practitioner’s statement on second request”.  Name and address, signed, dated.  This is essentially the first statement reiterated.

Next form is the “Second medical practitioner’s statement on second request”, and another reiteration of the first statement.   Name and address, signed, dated.

That completes the form-filling.  The act of suicide must take place within two weeks of the second request, or the procedure is no longer legal.

This walk through the form-filling allows us to draw some conclusions about the proposed process. They can be drawn quite independently of any ethical opinion one might have.  It is clear that the Bill is proposing to legalise assisted suicide on request.  To qualify, all you need to have is a condition that is life-shortening and which, in your opinion, renders your quality of life unacceptable.  I can’t think of a single significant chronic pathology that does not shorten life and diminish its quality.  Implicit in the wording of the forms is the idea that it is the patient, not the doctor, who can best evaluate his own quality of life.  As politicians are wont to say, “This is all about choice.”

The second thing to note is the way in which the patient’s loved ones have been removed from the process.  Indeed, they are disqualified from the process.  They have been replaced by a bureaucracy, as depicted by the forms.  An entire new discipline with its associated industry is being created; we might call it “thanatology”.

On Saturday I went to The Dream.  Based on a text by John Henry Cardinal Newman, Elgar’s is an intensely personal, religious and indeed Catholic work.  I think of it as a hymn to palliative care.  We meet Gerontius, first on his death bed, then when he has passed beyond death.  We experience the palliation of his fear.  I like to think of Gerontius’ Guardian Angel as a palliative care nurse.  Sir John Barbirolli recorded Gerontius in 1964, with Dame Janet Baker singing the part of the Angel, but he had first performed it in Sheffield in the 1940s, with Kathleen Ferrier in the role.  Apparently she sang with such searing intensity that the composure of the bass soloist David Franklin was shaken.  The thing about the voices of both Ferrier and Baker is that they are remarkable instruments.  I like to think of Baker’s voice as the “ex-Primrose” Guarneri viola of 1697, while Ferrier’s is the Archinto Strad of 1696.  The voice of the viola is dark, mellow, compassionate, and palliative.  In this context, there is a poignancy in Ferrier’s death in 1953, from metastatic breast cancer, at the age of 41.

On Saturday evening, Sarah Connolly was the Amati viola of 1600.

Who can say what he might think, or wish for, in an extremity of condition?  Who would not have compassion for someone moved to put an end to the torment of a loved one?  Who indeed would not wish our parliamentarians well in trying to clarify the law?  Yet I cannot believe compassion will ever be captured in a series of bureaucratic forms.  No matter how clever your jurisprudence, the next unique situation will always confound it.  It’s like the Heisenberg Uncertainty Principle.  The closer you scrutinise something, the fuzzier it becomes.

It is not behovely for one who has not been put to the test, to make sanctimonious remarks about the sanctity of life.  Yet recently I’ve had a strange experience.  Walking by a field of rapeseed, stopping to gaze at a river, standing under the burgeoning leaves of a Scots pine, I’ve become aware of a palliative sense of companionship, quiet, friendly, benign.

Maybe it’s just a dream.

I’ve been reading Freud all week.  The Interpretation of Dreams.  Occasionally, by way of antidote, I pause and read a few pages of James Thurber’s Let Your Mind Alone!  Then I return to the Herr Doktor Professor with renewed scepticism and say in a Columbus Ohio drawl, “Well, I’m not so sure about that!”

Freud’s thesis is that all dreams are meaningful.  He opposed the view that dreams are the mind’s way of sifting memories and discarding rubbish much as you would put waste paper through a shredder.  The discarded memories are all incoherent and disjointed like ticker tape.  But he went much further.  He said that all dreams without exception are wish fulfilments.

I can see why this idea met a lot of resistance.  I only have to look at my own dreams.  I have three recurring dreams.  (Freud called such dreams “perennial” and said he didn’t experience them.)  I will describe them in reverse chronological order.

After I stopped practising medicine I dreamt about medicine every night, without fail, night after night, for months.  For a long time I was on permanent night shift, with no nights off.  In my dream I am working in a hospital emergency department, at night.  I am trying to deal with some ghastly complicated clinical problem, I’m not making headway, and meanwhile the patient backlog is piling up.  And the dream seems to go on all night.  When I finally wake, there is a tremendous sense of relief that I no longer have to grapple with the complicated problem.  But there’s also a nagging sense that I am walking out on my colleagues at the end of my shift, leaving them to sort out all my unfinished business.

My second recurring dream relates to music.  Just before I went to Medical School I was playing viola in a number of ensembles.  My teacher was the principal viola of the Scottish National Orchestra (SNO, now RSNO), and occasionally he would smuggle me into the SNO and I would rehearse with them throughout the week and then play concerts in Edinburgh and Glasgow.

Now from time to time I still dream I am playing in the SNO – but in the present and with lapsed facility.  I’m sitting in the orchestra waiting to be identified as the person making the dreadful noise.  The conductor will dismiss me.  It will be a very public humiliation.  This dream even spills over into my waking life.  I recently ran into a retired RSNO member who invited me to play some chamber music.  I felt an intense sense of unease and, in explaining why I really wasn’t up to it, I said, “You’ve got to remember that when I played viola professionally it was so long ago that viola jokes hadn’t even been invented.”   He laughed and said, “That in itself is a viola joke.”  I did recently play in an amateur gig with an RSNO viola player and I told her of my dream.  She said she wasn’t in the least surprised.  She had a recurring dream in which she mistakes the orchestra dress code and turns up for a concert in the wrong attire.

But my third and oldest recurring dream has become the most bizarre and surreal.  In this dream I am a pupil back at school.  I started having this dream not long after I left, when I was 17, so at first my dream was not anomalous.  I remember a couple of guys who were 19 before they left.  One had had a protracted illness and the other a background of exotic foreign travel.

The school itself, in Glasgow’s west end, is accurately represented in the dream, (it looks like an open plan penitentiary) and I usually find myself in the first floor corridor of the north wing, just west of Room 11, where I studied mathematics for five years.  I have lost my class.  I am struggling with my timetable, trying to interpret where I ought to be.  I am dreading entering the classroom because, as with the SNO dream, I am dreaming this in real time and I know the idea of a middle-aged man still at school, and in school uniform, is utterly ridiculous.

If these dreams are wish fulfilments then the wishes are surely deeply concealed.  When Freud’s patients pointed out to him that many of their dreams were unpleasant, he explained that the wish-fulfilling aspect of the dream had merely been distorted and the distortion could often be explained in terms of events in the patient’s waking life, often on the day before the dream.  If Freud could not interpret the dream, he even had a fall-back position that seems to me a kind of reductio ad absurdum:  the patient had dreamed the dream to have the satisfaction of proving Freud wrong.

It is clear that my three recurring dreams are all anxiety dreams.  Further, they concern the relationship of an individual (me), to a large society or organisation.  They have the Kafkaesque quality of a vulnerable individual up against an impersonal and inimical authority.  And there is the dread of the vulnerable individual being exposed as an impostor.  I relate most of this to my school life.

When I was about thirteen, I and my class mates were given, as a home reader, The History of Henry Esmond by Thackeray.  The assignment was quite simply to read Henry Esmond with a view to answering a question on it in an examination.  No help was offered.  You may say that quarter was neither asked nor given.

There was never any possibility that I would read Henry Esmond.  I can’t remember how I got round that, but I do remember doing rather well with a character sketch of Mr Micawber, not having read David Copperfield.  I think I stole it out of a crib.  School taught me how to cheat.  I came away under the impression that the way to get on in life was to fake it.

Not that our teachers were unkind.  I think many of them felt as incarcerated as we did.  I remember towards the end of my final year, I wandered into the school one morning at quarter to ten, smack into the headmaster at the front gate.  He gave me a look of pained indulgence and wished me good morning.  We both knew the game was up.  I’d overstayed my welcome.  Time to move on.  At the end, after the prize-giving and all that, Miss Watson (principal maths) offered me a cigarette.  Maybe that has a Freudian interpretation.  But shouldn’t I have been offering the cigarette to Miss Watson?  Perhaps not.  As Freud himself said, sometimes a cigar is just a cigar.

I’m not sure if I’m fulfilling a wish in returning to school.  But I have a notion why I sometimes go and walk around its shadowy and insubstantial domain.  (Or is it I who am the ghost?)  I’ve got some piece of unfinished business there, and I can’t for the life of me think what it is.  There’s something I didn’t do, which I ought to have done, while I was there.  So I go back, from time to time, and wander the corridors, and struggle with my timetable, and think, what is it that I should have done, while I was here, that I failed to do?  What did I omit?  What have I forgotten?  What is that one thing that I failed to do?

Orthopaedic surgeons are not renowned for their social skills.  Sometimes I think that as part of their training they are given a special course on how to be abrasive.  A long time ago in a far off land in a distant galaxy I once referred to orthopaedics a man who’d had the misfortune to fall from a height and land on his feet, fracturing both heel bones.  The orthopod took one look at the x-rays, walked over to the patient, and said, “Basically mate, your feet are stuffed.”  Hold this thought.

On Friday I visited the “acute campus” that is the site of the newly opened South Glasgow University Hospital complex.  I wanted, albeit reluctantly, to confirm something with my own eyes.  It is this fundamental fact about that most sacred of British cows, the NHS: that while there are some wonderful doctors and nurses who occasionally get together to run some wonderful units, by and large the great clanking juggernaut that is the NHS continues to have no respect for the patients it purports to serve.

I know this because, tucked away round the back of the hospital, 250 metres from the grand entrance into the enormous airport terminal atrium with its M & S, and W H Smith, its restaurant and coffee bars and cash machines and self-check-in consoles, there is a small sliding door leading into a low-ceilinged waiting room, about the size of half a badminton court.  This is a thing called “A & E”.  Next to “A & E”, but distinct from it, is another unit, the Acute Assessment Unit.   That is really all you need to know.  But I can tell you on the basis of this brief description that if you have the misfortune to enter a system like this as a patient, basically mate, you’re stuffed.

Let me explain.  Let’s go back round to the front of the hospital.  What is its purpose?  Since we now know that acute care is being delivered round the back, the front must cater for “elective” or “scheduled” work.  This is confirmed by the fact that patients can check themselves in, much as they would if they were getting a boarding pass for a flight in an airport.  The patients are “ambulant”.  They may be attending an out-patient clinic, a diagnostic facility, or presenting for admission for an elective procedure or for planned surgery.  Given the grandeur of the surroundings (in stark contrast to the modest facilities round the back) we may suppose that elective health care delivery outranks acute health care delivery both in importance and in bulk.  This is confirmed by acute care signage and terminology.  “Accident & Emergency”, “A & E”, “Casualty” – these are now all exclusively British terms.  “Casualty” is the title of the flagship BBC emergency medicine soap.  It is salutary to look up “casual” in the dictionary.  Chambers has:

Casual  adj.  accidental: unforeseen: occasional: off-hand: negligent: unceremonious:  (of a worker) employed only for a short time, without fixed employment. – n. a chance or occasional visitor, labourer, pauper etc: a weed not naturalised… n. casualty that which falls out: an accident: a misfortune… casualty department, ward a hospital department, ward in which accidents are treated; casual ward formerly, a workhouse department for labourers, paupers etc.

That Dickensian paragraph is essentially a description of a British “A & E”.  Unscheduled care is an add-on, a little piece of pro bono beneficence handed down to the poor and needy as a special favour, so long as it doesn’t interfere with the essential work going on at the front of the hospital.  Indeed, “A & E” (it pains me to use that term but I suppose that’s what it’s called around here) is hardly thought of as part of the hospital at all.  That is the origin of the “four hour rule” prevalent in most acute hospitals throughout the UK.  Get 95% of the patients out of here as fast as possible, either home, or into the hospital where they can be properly looked after.  If I were to tell a hospital manager that the Emergency Department (to give it its proper term) is the most important and vital location in the whole hospital, he would look at me as if I were mad.  That is because he does not know about the phenomenal diagnostic and interventionist power of a properly resourced Emergency Department.

But it’s true.  It’s true because all medicine is acute.

There are two groups of people who know that all medicine is acute.  One are the health care providers who work in any form of primary or “undifferentiated” care.  This would include doctors either in General Practice or in Emergency Medicine.  The other group?  The patients themselves.  The primary care doctors and the patients know that all medicine is acute because they are the ones present from the beginning.  Every episode in health care starts with a Presenting Complaint.  “I’ve got a cough” – “I’ve got chest pain” – “My sore hip keeps me awake at night” – “I’m miserable”…   The patient says to the doctor, “I’ve got a problem.”  Occasionally, in the spheres of screening and case finding, it is the doctor who says to the patient, “You’ve got a problem.” All presenting complaints are unscheduled.  Nobody looks at their diary and says, “I’m going to crash my car next Thursday.”  I was very struck by something somebody – not a patient – said to me once at a Christmas Party.  “A minute before I took my stroke I felt very well; I didn’t know I was going to take a stroke.”

Because GPs and emergency physicians are dealing with acute problems all the time, they are very good at gauging levels of acuity; they know who needs to come into hospital.  A GP will happily refer one patient to hospital during a day’s work.  If he refers two, he wonders if he is pushing his luck.  He will bend over backwards not to refer anybody else.  If he refers three, he will be abjectly apologetic.  “Sorry to bother you again…”  But it needn’t be this way.  We need to stop thinking that an admission to hospital represents some kind of societal failure.  Doctors call it “acopia” – failure to cope – the most cynical word in the medical lexicon.   In fact, helping patients who are unable to cope outside of hospital is what a hospital is primarily for.  That is why the preposterous opulence of the front door of the new hospital is such a travesty.  It’s a huge confidence trick.  All these people checking themselves in at the state-of-the-art consoles, they are on a waiting list.  The front of the hospital is designed to impress; it’s all about prestige.  Yet at the end of the day this is a cathedral dedicated to the art of waiting.  There’s an irony inherent in the very vastness of this atrium; it’s a monument to vacuity.  But Medicine is not remotely like an airport check-in counter, much as the managers would like it to be so.  Medicine is messy and complicated and unpredictable.  Hospitals that dedicate their grand entrances to the art of waiting are trying to remove themselves from the hurly-burly of life.  But they need to do precisely the opposite.  They need to roll up their sleeves and engage with the real world.  They need to move their focus of attention closer to the point at which pathological processes become evident.  So let’s go round to the back of the hospital again.

Something needs to be said about that other unit – the acute assessment unit.  In most acute British hospitals, there are two modes of entry into hospital for patients who are acutely unwell.  If a patient’s GP has made contact with an in-patient specialty to arrange an admission, then the patient is likely to go through the acute assessment unit, unless the patient is deemed to be unstable, in which case the transfer to hospital will be by ambulance and into the Emergency Department where there are resuscitation facilities.  If the patient self-presents, he will be “triaged” into the Emergency Department.  The GP-bespoke acute assessment patient has a higher status than the self-presenting “A & E” patient.  An in-patient service has already assumed ownership of the former, while the latter is not really in the hospital at all.  In other words, there is an apartheid system working at the front (ie the back) of most British hospitals.  If patients are unaware of this, it is because they have no idea of the tribalism, the ancient and acrimonious turf wars that exist among the medical specialties and Royal Colleges.  In particular, there is a schism between the specialties of Emergency Medicine and what used to be called “General Medicine” or “Internal Medicine”.  Many of the consultants in these areas don’t particularly mind.  The Emergency medicine consultants are happy to concentrate on unstable patients, and the physicians are happy not to have the acute responsibility of resuscitating them.   But neither side are prepared to give up their perception of their own sphere of interest.

I see an opportunity here which, if embraced, really could make British hospitals “world leaders” in acute care.  Emergency Departments and Acute Assessment Units should amalgamate.  Neither side would be giving up anything, but both sides would be taking on considerably more, while sharing the burden.  The greater change of mind set would be in that of the acute care physician working in the acute assessment unit.  I’m basically suggesting that, if a general physician wants to work at the coal face of acute care, he should broaden his diagnostic repertoire and become an emergency physician.

Then the amalgamated units should move out of the back of the hospital and occupy that absurd mausoleum at the front of the building, get rid of all the retail and the money changers, and turn the front door into a state-of-the-art Department of Emergency Medicine, designed, funded, and staffed to cope with everything that is thrown at it in an expert and expeditious fashion.  Put all the acute services together, right at the front of the hospital – the emergency department, radiology, diagnostic suites, catheter labs, intensive care, and theatre – all next to one another.  These are the locations where medical interventions happen.  The crucial role of the general ward is in observation and nursing care.  Here, patients get better.  It is a mistake to imagine that doctors cure people.  They merely try to engineer the optimal conditions that will allow nature to heal the patient, with the best possible outcome.  The mysterious thing about pathology is that the disease and the cure are one and the same.  And time really is the great healer.

We need to relocate the Department of Emergency Medicine to the hospital front door.  If we don’t do this, if we don’t practise a form of acute care medicine more appropriate for the twenty-first century, then basically, mate, you’re stuffed.

It was the best of times, it was the worst of times…

I was in Edinburgh on the day of the general election, and took a walk up the Royal Mile all the way from the Scottish Parliament to Edinburgh Castle.  The usual street theatre was in evidence.  I stopped – I am the eternal average man – and joined a crowd of tourists to watch a man juggle three flaming torches while simultaneously bouncing a ball on his head.  This is Edinburgh on show, depicted on a shortbread tin, Edinburgh in inverted commas.  It’s a permanent Edinburgh Festival Fringe.

Next morning, according to the First Minister, “The political firmament, the tectonic plates in Scottish politics, have shifted.  What we are seeing is a historic watershed.”  I am inclined to forgive her for mixing her metaphors; she had after all been up all night.  Post-seism, not only the watercourses, even the stars above have altered their trajectory.  That is one Big Shoogle.  The newspapers said, “The SNP tsunami has caused a seismic shift…”  These tectonic plates again. Doesn’t the earthquake cause the tsunami?  But I quibble.

That day, I happened to be in Glasgow.  Glasgow is 44 miles from Edinburgh, but culturally it might as well be 44 light years.  Perhaps if I took a stroll down Buchanan Street from the Royal Concert Hall to the Clyde I might figure out why.  I stopped for a coffee in the concert hall.  In the loo, a guy started talking at me in that abrupt way Glaswegians start up a conversation.

“Aye she wanted the Tories back all along!”

“I might not agree with you.”

“Believe me – it was all planned!”

I was non-committal.  “We live in interesting times.”   He gave me a withering look.  Meanwhile I was trying to turn the tap off – difficult as the faucet handle had come off.

“It’s been like that for weeks now!”

The Concert Hall is the home of the Royal Scottish National Orchestra.  Around the time when the Glasgow tram lines were being ripped up, the St Andrew’s Hall was burned down and the RSNO (then SNO) moved into temporary accommodation.  The city fathers turned Glasgow into an asphalt jungle of super highways on concrete stilts but took thirty years to finance a decent concert hall. (I remember as a child attending an SNO concert for school children held in a disused cinema in the middle of a building site.  The orchestra played Webern’s Six Pieces – an astonishing thing to do at a children’s concert.  The fourth movement is a funeral march culminating in a huge percussive crescendo towards a silence Sir Simon Rattle has described as “deafening”.  It was hard to distinguish the bass drum from the pile driver operating just outside and, in the event, the silence did indeed turn out to be deafening.  Apologetically, the conductor folded before the competition and cut the concert short.)

Back outside, I negotiate the picnic lunches on the concert hall steps.  There’s a move afoot to take the steps away but the lunchers are not happy.  Squatters’ rights.

Looking south down the slope of Buchanan Street towards the Clyde, the perspective is foreshortened and it’s like staring at a Brueghel painting full of jugglers and tumblers.  But it doesn’t look like a shortbread tin.  Somehow it’s the real deal.  Beside Donald Dewar’s statue a guy has put up a tightrope between two lampposts and is cavorting around on it with extraordinary facility, to the deafening clatter of a bunch of drummers and a bagpiper, all dressed in faded dun plaid.  Terrifying.  Was it Wellington who said of his troops on the eve of Waterloo, “I don’t know if they frighten the enemy, but they certainly scare the s*** out of me.”  If there are any tourists, they are invisible.

Down by the river, things get quieter.  I like to walk west along the river bank occasionally swapping sides over the bridges – the suspension bridge, Jamaica Bridge, Bells Bridge, the Millennium Bridge.  This is a part of Glasgow that has become familiar to many because, on the south bank of the Clyde, political pundits emerge from BBC Scotland and talk to Huw Edwards in London against the back drop of a defunct crane, the Squinty Bridge, the SECC, and the Hydro.  It’s all rather chic.  When I was growing up in Glasgow nobody in their right mind would have ventured down here.  Dereliction.

But on this occasion I turn east.  Glasgow is a very territorial city.  I know people from the west end of Glasgow who have never ventured even as far east as Glasgow Green.  It’s as if there is a Berlin Wall at the Salt Market.

And here, just to the east of the city centre, lies the great mystery about Glasgow and Edinburgh. If you are male, resident in the leafy suburb of Barnton in West Edinburgh, you can expect to live until you are 85.  If you are male, resident here where I walk now, you can expect to live until you are 55.

And nobody knows why.

Let’s talk about the elephant in the room.

I once attended a lecture given by the charismatic John Guillebaud, Emeritus Professor of family planning and reproductive health at UCL.  He put up a slide of the elephant in the room.  It depicted a board room, with a group of people gathered round a mahogany table and, beside it, dwarfing everything, a large elephant.  It’s a farcical image.  You could imagine yourself seated at the table, thinking, why is everybody pretending the elephant isn’t there?  Am I imagining it?  Should I mention it?

Prof Guillebaud is very interested in the potential effect of effective contraception on world population. I nearly juxtaposed the words “population” and “control” there but that is a great taboo for those in the west seriously interested in addressing the elephant in the room.  It’s political dynamite.  When war, famine, and rising sea levels cause people to drift across the Mediterranean it is much easier for the PM to emerge from a meeting in Brussels and say, “We’re going to put a stop to this by blowing up the traffickers’ boats.”

But I digress.  The elephant in the room this week is of course the General Election.  There are three topics to be avoided in polite middle class discourse – sex, religion, and politics.  Have you experienced that rueful feeling when you come away from a social gathering where you have indulged in some robust conversation, grown a little impassioned, perhaps even intemperate, and departed with a vague sense of free floating anxiety?  “Maybe I shouldn’t have said that.” Last September before the Scottish Referendum I would go to dinner parties, talk about the weather, and ignore the elephant in the room.

Joe Epstein, one of the founding fathers of emergency medicine in Australasia, another charismatic speaker, used to give the following advice to those of us involved in the furthering of emergency medicine amid the tribal collegiate turf wars of the medical colleges:  don’t be seduced into a fruitless argument with somebody whose entrenched views you will never change.  That is pretty much a description of a political leaders’ debate.  Have you ever seen a politician on Question Time listen to an opponent and say, “That’s a good point; I never thought of it that way; you’ve changed my mind”?  Last night on the news I caught a snatch of conversation from a bitter and acrimonious encounter in Edinburgh.  One of the party leaders said to another, “Are you calling me a liar?”   It’s excruciating.  I switched off.  I’m rationing myself.  Only three days of campaigning left to endure.

But let’s talk about the elephant in the room.  I’m going to stick my neck out and make a prediction.  I think Mr Cameron is going to get a second term.  He’s the incumbent; and he’s stuck with it.

This opinion is entirely non-partisan.  It’s based on the “Red Lines” everybody has started drawing.  Mr Cameron won’t lead a government that is not offering an in-out EU referendum; and Mr Miliband won’t have any truck with the SNP.   Politicians aren’t usually that specific.  They usually leave themselves some wriggle room.  This is all very mysterious.  And now Mr Miliband has come out with his six policy statements, “A better plan, a better future”.  And he has, literally, set them in stone, with a pledge to implant them, like a Henge, in the back garden of No 10.  I list them here in full, and ask you to examine them, not so much as a student of politics, but as a literary critic.  Examine them the way F R Leavis, at his most ferocious, might have done so.

1. A strong economic foundation.
2. Higher living standards for working families.
3. An NHS with time to care.
4. Controls on immigration.
5. A country where the next generation can do better than the last.
6. Houses to buy and action on rents.

Who would not buy into all that?  But then again, it’s so abstract as to be completely meaningless.  If Mr Miliband were running for the Presidency of the USA he might as well have run on a “mom and apple pie” ticket.  We might invoke Leavis’ accusation against Shelley and his “weak grasp upon the actual”.  Isn’t it ironic that something as non-concrete as “A better plan, a better future” should be set in stone? There isn’t a policy or a pledge in there.  Scrap Trident, or even Keep Trident – these are pledges.  Mr Miliband’s limestone menhir is completely vapid. He must know it.  We all know it.  So here’s the question.  In this day and age when the voting public have become profoundly suspicious of gimmickry, and when they have grown to admire certain women politicians who “talk normal” and espouse clearly defined policies, why on earth would Mr Miliband choose to insult everybody’s intelligence?

The only rational explanation I can find is that he has decided the top job is such a poisoned chalice that he doesn’t want it.  Maybe he knows the “recovery” is a figment, and that, if Mr Balls were to walk into No 11, he might find a note: “There is no money.”

Mr Cameron doesn’t want to lead a coalition again.  “Been there, done that, got the T shirt.”  But he may have no choice.

There is one alternative scenario:  On Friday morning Mr Miliband has a slight attack of post traumatic amnesia – I’m leaving myself some wriggle room.  After all it’s not going to contradict anything carved on his Henge.  So he talks to the other progressive parties.   Including the elephant in the room:

The SNP.